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PROOF OF INSURANCE (2018 - 2019) CLOSED AC' R0 CERTIFICATE OF LIABILITY INS SU DATEIMMIDDIYYYY)
NCE 5/7/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT, It the certificate holder is an ADDITIONAL INSURED, the Policy(les) must be endorsed. II SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this cortificate does not confer rights to the
certificate holder In lieu of such endolrsement(s').
PRODUCER ... .. ..... �%li�Julle gong .. .. 1.plANk,.RN�I,
IQ Risk (949)679-3701
(949)679-3700
7tek'co
,.-.____ ...m..._..... r 9- 0 0
ance
m
38 8xocutiverPsrk,$Suitee320LLC jm�or( .�m.................w..3.... ....,.. ..
Irvine, CA 92614 INSURER(sIAFFQ,RDINQ, _,.......
, COVERAGE
MNatiass5EasITmmGaarwaraca,ata _.. 38910 ._ .
INSUREDI y 4
ReI�I�_Falls Lake Fine and Cad�ualt 1588 ,
CC LAYNE A SONS INC. INSURERc
.,., .....
216 Standard Street !NSUW :
., .............�.w.._w..,wwww-._...,...... . ..................................,.....wwww..,.....,..................,...............................,. .,..,
E1 Segundo, CA 90245 INSURER E.
INSURER F:
COVERAGES CERTIFICATE NUMBER:CL182103315 REVISION'NUMBER-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI D BELOW HAVE BEENISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. 0 I Y REQUIREMENT, TERMCONDITION F ANY CONTRACTO OTHER DOCUMENTET TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS D CONDITIONS OF SUCH POLICIES.LIMITS Y HAVE BEEN REDUCED BY PAID
iPOU-0,00
PAICLAIMS.
YY).
gK§W .LS(a(' POU .EYPoLlVEip
LTR INSURANCE ' NUMBER Y
�i
COMMERCIALLIMITS
LITY EACH
GENERAL el �6 ; 1,000,000
OCCUR , 100,000
A C S ( ...
X Y 010061552-0 7/1/7018 2/1/2019 MED EXP( ) axClndald
PERSONAL A AM IWURY i 1,000,
S,,FN L AGw','v RC(G.A"I";LIMIT APPLIES PER GENERAL AGGREGATE ..S 2,000,000
x Pof'1(^y C I L .S 2 0 000
PRD-
JI�CT PRO TS- MPTP .
00,
OTHER
AUTDMOWLELIABILITY .. .. I, MtII'JV('MV7'kil'+(Cmk, �ldda(p1. .
Bwlora.lNc�d(IAIIa.. _ .. ...
ANY ADDILY INJURY(P ) 9 -
ALL OVMED SCHEDULED
LED
AUT Ain BODILY I j, „, ....,..,.., _--- .......:
L
HIRED AUT AUTOSED (p9rAp" uRMn..................................
1
LIAR tl
PuCXU p
A EXCESS CLAMS-M AREGNTs A000wY00q
DD RETENrIPN$ 0100061562-0 2/1/2018 2/1/2019 1
yy
PEk 0101,
.I�. .,... ............................
13 IMandam(oryInNH, AP"aall,Ixl. Mrr'Ihl J 1 oo8293-00 2/1/201 2/1/2019 L ¢rlaR: a! I'AEkuR I)bL,al„s 1.000.000
M L L CAG 1 ACC6DC
y� ELDISEASE-POLICY...
pgn v ( I ., Lw 1C, / u IT I6 1.000,000
,1b(^�1+(":RIK�1 Y4)F�I("7F C7F'FI�NA"i'V(7hd',�N'�*p¢'NM
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLE-(ICORD 101,Addldonal Remarks Schedule,may be attached N mora apace to required)
*10;Days Notice of Cancellation for Non-Payment of Premium.
The, City of 81 Segundo is named as Additional Insured per General Liability.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City Of 81 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
81 Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
Julie Wong/JULIE
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025(201401)
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS
SCHEDULED PERSON OR ORGANIZATION
Attached To and FormingPart o Poli E ective Date o Endorsement 7Nomed insure
f ry � fd '
0100061552-0 02/01/201812:01AM at the Named Insured yne&Sons Inc
address shown on the Declarations
Additional Premium., Return Premium:
$0 $0
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE _
Name of Additional Insured_Person(s)or Organization(s): Location(s)of Covered Operations
Blanket,as required by written contract.
Information required to complete this Schedule,if not shown above,will be shown in the Declarations.
A. Section 11—Who Is An Insured is amended to include B. With respect to the insurance afforded to these
as an additional insured the person(s) or additional insureds,the following additional exclusions
organizatlon(s) shown In the Schedule, but only with apply:
respect to liability for "bodily Injury", "property This insurance does not apply to "bodily Injury" or
damage or personal and advertising Injurycaused, "property damage"occurring after:
in whole or in part,by:
1. All work, including materials, parts or equipment
1. Your acts or omissions;or furnished in connection with such work, on the
2. The acts or omissions of those acting on your project (other than service, maintenance or
behalf; repairs) to be performed by or on behalf of the
in the performance of your ongoing operations for the additional Insured(s) at the location of the covered
additional Insured(s) at the location(s) designated operations has been completed;or
above. 2. That portion of"your work" out of which the injury
or damage arises has been put to its intended use
by any person or organization other than another
contractor or subcontractor engaged in performing
operations for a principal as a part of the same
project.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CG 2010 07 04 0 ISO Properties,Inc.,2004 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
Attached To and FormingPort o Poli Effective Date o Endorsement f Policy ff f Nomed Insured
0100061552-0 02/01/201812:01AM at the Named Insured C C Layne&Sons Inc
address shown on the Declarations
$
Additional Premium: Return Premium:
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Additional Insured Person(s)or Organization(s) Location and Description of Completed Operations
Blanket,as required by written contract. EXCLUDES ALL NEW RESIDENTIAL CONSTRUCTION
"Your work"does not include"new residential
construction",which means any building or structure not
previously occupied,and designed or intended for
occupancy in whole or in part as a residence by any person
or persons."New residential construction"does not include
apartments or apartment buildings or assisted living
facilities.
Information required to complete this Schedule,if not shown above,will be shown in the Declarations.
Section II—Who Is An Insured is amended to include as
an additional insured the person(s) or organizations)
shown in the Schedule, but only with respect to liability
for "bodily injury" or "property damage" caused, in
whole or in part, by "your work" at the location desig-
nated and described in the schedule of this endorse-
ment performed for that additional insured and in-
cluded In the"products-completed operations hazard".
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CG 20 37 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY,PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT
Attached Ta and forming Part of PolicyEffective Date of Endorsement Named Insured
0100061552-0 02/01/201812:01AM at the Named Insured C C Layne&Sons Inc
address shown on the Declaratlons
Additional Premlum Return Premium:
$0 $0 _..__.�.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
ENVIRONMENTAL CONTRACTING AND PROFESSIONAL SERVICES LIABILITY COVERAGE
PRODUCTS POLLUTION LIABILITY COVERAGE
The insurance provided to Additional Insureds shall be excess with respect to any other valid and collectible insurance
available to the Additional Insured unless the written contract specifically requires that this insurance apply on a primary
and non-contributory basis,in which case this insurance shall be primary and non-contributory.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CAS5003 0717 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US-BLANKET
�W,_chQT6_a_nd—Forming Port of Policy Effective Date 11 of Endorsement r I I--1—--.__.'7Name.d insured....
nsu.r,ed
0100061552-0 02/01/2018 12:01AM at the Named Insured C C Layne&Sons Inc
address shown on the Declarations
.................................... m.,,., ....w_....w_ ,,, .__............._.._............". ... .....
1"Additional Premium: Return Premium:
1
so 0
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
SECTION IV—CONDITIONS,8.Transfer of Rights of Recovery against Others to Us is amended by the addition of the
following:
We waive any right of recovery we may have against persons or organizations because of payments we make for injury or
damage arising out of"your work"done under a written contract with that person or organization wherein you have agreed
to provide this waiver.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CAS4002 0110 Page 1 of 1
AC CERTIFICATE T F LIABILITY
........_. ... 05/21/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFO TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT, If the corti'ticate holder Is anADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSUREDprovisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on
this corti'flcato does not confer'right's to the certificate holder In Itou of such endorsement(*).
a�aPRODUCER COMA0
Tom BPundid a License 0479988 F71oNE .Ymm......Ole Hernandez r Is AX .
10-322.0831
"•MA,AIL P�„l'tcranx�agNamttk°alrroduago vont.,,,, t ,'.1
w 214 Standard St. Ste 8
�PNIN"hll
ER AFFORDING
EI Segundo CA 90245 P State IF-arrRri Mutual Automobile sur Company 61L s
................ Isu111111 A: Insurance t'atlra>an 2517&
INSURED INSLIRER a:
C C LAYNE&SONS INC eN c:
......................®r.....,.......
216 STANDARD ST i INSURER
RISUREA E:
EL SEGUNDO CA 90245 INSURM., F
COVERAGES CERTIFICATE NUMBER:
REVISION i NUMBER:
THIS IS TO Cl R'rPFY' T'HA'I I'IjF PO ICtP S OF WSpYfdC4N t: 9 NSIED BELOW HAVE BEEN iSSL)'l:D TO E INSURED NAMED ABOVE FOR THE POLICY rrElr�laJt�
INDICATED. N.OTWI'lllSTANLANG,ANY AEOUIRCMENt I'I:RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 8l. I a;tAD 11r1 MAY PERTAIN. 1HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS CONDITIONS uAaiurr SUCH POLICIES,LIMITS SHOWN MAY HAVE BEENP IC REDUCED'BY PAIDCLAIMS.EACH 4'11 Ctjf?R d+s�w
I1i uofYCk' rr wYw
TYVErJr IINSURANCEY "Pjy� ICd, I 1M10'TS
C11 OMMERaaA GENERA 1
,�M k�CI t"I9 Iii b4 tl 4 l
CLAIMS-MADE OCCUR
..ED EXP INri ¢e� �rarlw�mlq ��
..N'LGGREGA❑TE.....C.....
fur R�O AL I—ADV INJURY S
LIMIT APPLIES PER ... ..
ICY PERQ LOC
,..41a,E rpf,I�dY,A.rnr�"y�kkl"�,�,n k: 1
r"6a910!1!S•COMPIOP AGG 1
. ......_..._..4;11'ddk'i,,..._.. ............... . .
auTOMOBM LIABILITY ANYAuro Y Y 499 1656-C26-75C � INr �r"dk°d4MI� s 1,000.040
03/26/2018 09128!2018 w mm
_ BODILY INJURY(Per pwsw) $
QUAUTOSED
BODILY INJURY.(P...... "..' ..
A OS ONLY Per ep:ruNuddm^+I,P S
PROP
HIRED NON-OWNED LY ,,,,,„,,,,,,��.,,,,,,,,,,..�....._m wl”4vdt'4efftllP'111MINJu:d@,,,,.
—
UMBRELLA LIAR OCCUR Y ., S
AUTOS ONLY A II
EXCESS LIAe..,,,, ;7LMIY.T* ECHLC.�4TIM"dd6..P�r,..L
Ndd.bl ryry
---» - "rIF1;I9�d_I.PN u_I�I�kI
r'p&��Ca d�I�1'IN81.DMbI,
LLABUW
ANYCrwk F. IpPdYERt N$AN N�CN) I{P4d' Y
1YaR11E COMPENSATION
IN
® El El 1�,4 ha Af:rl 117k•Mdl,,, f.
I drd si d,,Nrk VN: NIA
VtJIMNFMAIb�kd C�^L
Msarozlelcory In NRI
MA �r�d Mdil:'�d:artl^wb wuY�Iear 4'I d'SIJEA.iL EAf dr&d-k.,47 M"IWA S I,
I
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,AdMOW Remarks ectodule,any be dWchad N mom apace is )
2006 FORD F350 SO CREW CAB VIN 1FTWW31P46EA08216
Job site:Vista Park
........... �..............................._W. � W_
CERTIFICATE HOLDER !CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St
AUTHORMED REPRESENTATIVE
ElSegund CA 90245
®1988'» 0'tlCORD "PORATION. All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD
1001483 132810.12 03-16-2016
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed.4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perform work under a written contract that requires you to obtain this agreement from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 225% of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization Job Description
Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured
during the policy period where by written contract a waiver
of subrogation is required prior to the commencement of
work.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective:05/22/2018 Policy No.FLA008293-00 Endorsement No.
Insurance Company: Falls Lake Fire&Casualty
Company Insured:CC LAYNE&SONS INC.(A Corp)
Countersigned By
©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved.